The Department of Veterans Affairs’ (VA’s) Supremacy Project drew push back from the American Medical Association (AMA) and more than 100 other medical organizations. The project would involve developing National Standards of Practice for 48 categories of health care professionals that would supersede state scope of practice and licensure laws. The organizations issued a letter on July 29, 2021, to VA Secretary Denis McDonough in hopes that the VA would reconsider implementation of the National Standards of Practice.1

Gerald E. Harmon, MD, AMA President, said that these standards “will have the unintended consequence of reducing the quality of health care for veterans, many of whom suffer from complex symptoms that require expertise from trained medical professionals.”2 The VA did not provide a transparent process by which public stakeholders were provided with an adequate opportunity to review and provide meaningful input into the national standards of practice, the organizations stating, adding that the VA policies will have implications for standards of care outside of the VA setting.

“There needs to be a meaningful opportunity for stakeholders to provide feedback that is incorporated into the National Standards of Practice for all occupations, especially since the Interim Final Rule (IFR) did not provide a significant opportunity for public comment,” the organizations stated in the letter.  They asked the VA to “initiate a meaningful process for the collection, dissemination, and inclusion of stakeholder input as early into the process as possible.”

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The American Academy of PAs (AAPA), however, supports the VA “in its efforts to ensure our nation’s veterans have access to high-quality care and services,” a spokesperson for the AAPA said in an interview. “This [rule] will no longer hinder PAs while they work and will allow them to provide patient care to the full extent of their education, training, and experience,” AAPA added.

The organization “is proud of the high-quality medical care provided to our nation’s veterans by the 2650 full-time PAs that deliver care to veterans within the VA system. Approximately 24% of PAs delivering care at the VA are veterans themselves,” said AAPA.

Interim Final Rule

In November 2020, the VA issued an interim final rule establishing its authority to establish national standards of practice for physician and non-MD health care professionals employed within the VA system. According to Federal Register, the rule “will confirm VA’s continuing practice of authorizing VA health care professionals to deliver health care services in a state other than the health care professional’s state of licensure, registration, certification, or other requirement.”1

This ruling continues the licensure extensions given by the organization to nurse practitioners (NPs), PAs, and other health care professionals within the VA at the beginning of the COVID-19 pandemic under the National Emergencies Act (50 USC 1601 et seq.) and consistent with section 1135 of the Social Security Act (SSA), as amended (42 USC 1320b-5).

“As a result of responding to the needs of our veteran population and other non-veteran beneficiaries during the COVID-19 National Emergency, where VA has had to shift health care professionals to other locations or duties to assist in the care of those affected by this pandemic, VA has become acutely aware of the need to promulgate this rule to clarify the policies governing VA’s provision of health care,” noted the VA.

“The new rule confirms that VA health care professionals may practice their profession consistent with the scope and requirements of their VA employment” in any state where there is a need, noted the VA. In addition, the rule confirms “VA’s authority to establish national standards of practice for health care professions via policy, which will govern their employment, subject only to State laws where the health care professional is licensed, credentialed, registered, or subject to some other State requirements that do not unduly interfere with those duties.”

A conflicting State law “is one that would unduly interfere with the fulfillment of a VA health care professional’s Federal duties,” according to the VA. The rule only applies to VA health care professionals and not contractors working in VA medical facilities or those working in the community.

The new legislation also grants the ability for VA health care professionals to administer medication without a provider co-signature. In 2016, the VA proposed and later implemented a rule allowing advance-practice nurses within their medical system to practice at the top of their licenses without physician supervision. “As it pertains to nursing, almost all States permit nurses to follow a protocol; however, some States, such as New York, North Carolina, and South Carolina, do not permit nurses to follow a protocol without a provider co-signature,” stated the legislature. Under the new rule, VA health care professionals will be protected against State action when they adhere to VA’s national standards of practice.


1. O’Reilly KB. Why VA’s move to nationalize standards of practice is misguided. July 29, 2021. Accessed August 10, 2021.

2. AMA: VA misfires on standards for oversight of health care professionals. Press release. American Medical Association. July 29, 2021. Accessed August 10, 2021.

3. Federal Register. Authority of VA professionals to practice health care. Accessed August 10, 2021.